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By D. Kippler. Eastern Kentucky University.

Studies of how conversation affects intracranial pressure remain inconclusive; familiar voices effective 10 mg metoclopramide, such as family order 10mg metoclopramide with amex, may reduce anxiety (Odell 1996) buy metoclopramide 10mg low cost, but more studies suggest they have no significant effect (Treloar et al buy 10 mg metoclopramide fast delivery. Where visitors do cause undue distress, nurses may need to intervene to enable patients to rest, but visits that provide therapeutic benefits should be encouraged. Good nursing documentation can be a valuable means to communicate the effects of visitors. While the prime duty of nurses is to their patients, care of relatives is an important, albeit secondary, nursing role. They also need adequate rest themselves; they may feel obliged to stay by the bedside, exhausting both themselves and the patient; thus, planning care with the next-of-kin can prove beneficial to all. Providing somewhere to stay and access to catering facilities can greatly reduce the stress experienced by relatives. More invasive methods of assessment inevitably incur greater risks, but may provide more useful information to guide treatment. As with monitoring any aspect of patient care, benefits and burdens of each approach should be individualised to the patient, and justified by the extent to which they usefully guide treatments and the care given. Further reading Menon (1997) offers a useful overview of neurological monitoring, while Odell (1996) offers a comprehensive nursing perspective. Feldman and Robertson (1997) describe jugular venous oxygen saturation monitoring. North and Reilly (1994) offer a reasonable overview of intracranial pressure and monitoring, which can be usefully supplemented by Hickman et al. Nurses should consider the effects of their activities on intracranial pressure; Rising (1993) and Price (1998) give useful overviews of potential problems. At a party following a successful rugby game, Mark fell out of a second-floor window and sustained a head injury with fractured right elbow and pelvis. Mark’s fractures were stabilised and intracranial pressure monitoring was initiated. He was invasively ventilated, sedated with midazolam and fentanyl infusions with pancuronium administered to promote muscle relaxation. What is the likely cause and significance of his temperature and blood sugar results? Since most pathophysiological processes originate at cellular level, Chapter 23 gives an overview of cellular pathology. Multiple, often interacting, pathology creates complex links between the pathologies and treatments discussed in this section, but chapters are then grouped largely by systems and treatments, starting with those more obviously related to cellular pathology: myocardial infarction, shock, multiorgan dysfunction syndrome and acute respiratory distress syndrome. These chapters do include some discussion of treatments, but further treatments are discussed in the next group of chapters: nitric oxide, alternative modes of ventilation and cardiac surgery. Two frequent complications of critical illness are discussed next: disseminated intravascular coagulation and acute renal failure. Further treatments are then discussed: fluid management, (positive) inotropes and haemofiltration. Issues surrounding transplantation (donors and recipients) are discussed in Chapter 43; care of patients following graft surgery is covered in the chapter on hepatic transplants. The complex interaction between systems necessitates holistic care, and so cross- references are given to other chapters; the reductionist presentation of each chapter is Pathophysiology and treatments 233 designed to assist easy reference by readers wishing to find out more about each pathophysiological process. Chapter 23 Cellular pathology Introduction Focus on visible macrophysiology (systems and organs) has increasingly been replaced by recognition that disease processes originate primarily at microphysiological levels; organ/system failure is more a symptom of widespread cell failure. This chapter therefore outlines pathological mechanisms underlying most critical illnesses; hence its placement before discussion on more familiar macrodisease processes. Recent growth in the understanding of microphysiological and microbiological processes necessitates selection of key aspects. Much remains to be discovered, clarified or proven; knowledge growth can rapidly outdate material covered in even relatively recent courses and texts. This chapter therefore begins with a brief revision of cell physiology; if unfamiliar, this should be supplemented from anatomy texts. The importance of cellular pathology in most diseases is reflected in the many references to this chapter in later ones; readers may find sections in this chapter useful as reference points for later use. The movement of electrolytes across the membrane creates the action potential (see Chapter 21) needed for muscle movement: potassium leak during the resting phase of action potential creates a negative intracellular charge (−20 to −200 millivolts), causing influx of positively charged ions. Sugar (for cellular energy production) influx is facilitated by insulin, hence hyperglycaemia, but lack of energy when insulin production or function is impaired. Cell membranes, therefore, maintain intracellular homeostasis; damage to the cell membrane disrupts cell function, with extensive damage resulting in organ dysfunction. However, with anaerobic metabolism most intracellular pyruvic acid is converted to lactic acid, which then diffuses out of cells creating metabolic acidosis.

If the coronary arteries become completely blocked and the flow of blood is cut off buy metoclopramide 10mg fast delivery, a heart attack (myocardial infarction) occurs cheap 10 mg metoclopramide overnight delivery, which results in damage to the heart muscle order 10mg metoclopramide fast delivery. H High blood pressure buy cheap metoclopramide 10mg online, high levels of cholesterol and triglycerides in the blood, and smoking can all contribute to the development of plaque. Inflammation causes damage to the arterial walls and further narrows the passageways. Years of smoking, stress, high blood pressure and cholesterol, uncontrolled blood sugar (diabetes), and poor diet take a toll on your heart and contribute to the development of heart disease. The good news is that there are many ways to keep your heart healthy and reduce your risk of heart disease. For example, obesity often leads to diabetes and high blood pressure and cholesterol. This cluster of problems is called metabolic syndrome, which greatly increases the risk of heart disease. In recent years, research has identified other factors that may increase your risk of heart disease. High levels of fibrinogen may promote excessive clumping of platelets, which can cause a clot, lead- ing to a heart attack or stroke. Stud- ies suggest that elevated homocysteine increases the risk of heart disease by causing damage to the lining of the arteries and promoting clots. Homocysteine metabolism is controlled by vitamins B6, B12, and folic acid, and a deficiency of these nutrients can increase levels. The protein that carries lipoprotein (a) may disrupt your body’s ability to dissolve blood clots, and high levels of this substance may increase the risk of cardiovascular disease. If these approaches aren’t effective, then your doctor will likely prescribe a medication depending on your needs. There are drugs to lower cholesterol or blood pressure, which are mentioned in those sections of this book. Low-dose daily aspirin (81 mg daily) is often recommended to thin the blood and reduce the risk of clotting. For those with angina, nitroglycerin tablets, spray, or patches may be used to open up the coronary arteries and improve blood flow. There are also various procedures, such as angioplasty and coronary artery by- pass surgery, which can be done to improve blood flow. Try to eat three servings per week of fresh coldwater fish such as salmon, trout, herring, mackerel, and tuna. Higher amounts can be hard on the liver and increase blood pressure and the risk of heart disease. Nuts contain fibre and nutrients such as vitamin E, alpha-linolenic acid, magnesium, potassium, and arginine, which are important for heart health. Although nuts are high in calories, some studies have found that increasing nut consumption by several hundred calories per day does not cause weight gain. Insoluble fibre—which is found in whole grains, vegetables, and fruits—does not lower cholesterol, but studies have shown that it helps protect against heart disease. Fruits and vegetables also contain vital antioxidants and studies have shown that those who consume antioxidant-rich diets have lower rates of heart disease. Substituting as little as 20 g per day of soy protein for animal protein can significantly lower cholesterol. Avoid adding salt to foods and minimize eating processed and fast foods such as deli meats, snacks (chips, pretzels), french fries, and burgers. The 2 percent refers to the fraction of volume filled by fat, not the percentage of calories coming from fat. Many snack food companies are now making products that are free of trans fatty acids. Lifestyle Suggestions • Don’t smoke, and avoid second-hand smoke, as this increases many risk factors for heart disease. Losing even 5–10 percent of excess weight can lower cholesterol and blood pressure. Moderate-intensity activities, such as brisk walking, biking, or swim- ming, can reduce cholesterol and blood pressure and help with weight management. Stress causes the liver to increase the production of cholesterol, which is used to make stress hormones. If you have diabetes or are at risk for diabetes, work on improving your blood sugar levels with exercise and a low-glycemic diet. Within one year of quitting, your risk of heart disease is half of that of a smoker’s. Coenzyme Q10: An antioxidant that has been widely studied and found to lower blood pressure and cholesterol and strengthen the function of the heart. They are thought to work by attaching to cholesterol in the digestive tract and carrying it out of the body. A sterol ester, called beta-sitosterol, has been shown to decrease cholesterol absorption by about 50 percent.

Begin evaluating this nursing of major importance in laying groundwork theorist’s Web site and as you thoughtfully consider for consistent generic metoclopramide 10 mg otc, credible metoclopramide 10mg overnight delivery, and authoritative each question buy 10mg metoclopramide fast delivery, assess whether or not the informa- research findings 10 mg metoclopramide fast delivery. Yes/No Who are authoritative sources who speak, write about, and Nursing authorities contribute to content. Are they contributors to the content on Practitioners of nursing contribute to the content. Yes/No What are the professional qualifications of these contribu- Other organizations use, refer to, or maintain links to tors? Evaluation of Authority: What are other major resources on this theory that are au- Acceptable/Not Acceptable thoritative? Information covers theory, practice, research, and Do authoritative sources show their credentials on the Web administration. Yes/No Does the resource provide information in a logical and easily Bibliography included. Evaluation of Content: Does the resource provide comprehensive, substantiated in- formation? Acceptable/Not Acceptable Does the information cover nursing research, administration, and education? Are you able to The Web site/resource is easy to use and well or- contact the webmaster from an onsite address? Yes/No Are you informed when you are seamlessly transferred to an- The Web site/resource is satisfying to visit. Are there fees or membership required to access the infor- Yes/No mation you need? This nursing theory resource will ground my inquiry as a credible, authoritative, and accurate source of information. Yes/No Reservations: ____________________________________________________________________________________ questions may not apply to all Web sites and may be • How comprehensive do you intend your analy- modified by the purpose of the Web site. Following are key reflective preparations that will When you have answered as many questions as help focus your activities: you are able to, synthesize your findings. White paper: Criteria for assessing the accuracy, credibility, currency, and trust- quality of health information on the Internet (working draft). Nursing decision making and the science of the Bartlett Publishers and National League for Nursing. The Nightingales Florence Nightingale transformed a “calling from were on an extended European tour, begun in 1818 God” and an intense spirituality into a new social shortly after their marriage. A reflection on this statement A legacy of humanism, liberal thinking, and love appears in a well-known quote from Notes on of speculative thought was bequeathed to Nursing (1859/1992): “Nature [i. His views on the educa- tion of God] alone cures … what nursing has to tion of women were far ahead of his time. Florence and her sis- Although Nightingale never defined human care or ter studied music; grammar; composition; modern caring in Notes on Nursing, there is no doubt that languages; Ancient Greek and Latin; constitutional her life in nursing exemplified and personified an history and Roman, Italian, German, and Turkish ethos of caring. It is model is yet to truly come of age in nursing or the Parthenope, the older sister, who clutches her fa- health care system. Justice- making is understood as a manifestation of com- passion and caring,“for it is our actions that brings about justice” (p. This chapter reiterates Nightingale’s life from the years 1820 to 1860, delineating the formative influences on her thinking and providing historical context for her ideas about nursing as we recall them today. Part of what follows is a well-known tale; yet it remains a tale that is irresistible, casting an age-old spell on the reader, like the flickering shadow of Nightingale and her famous lamp in the dark and dreary halls of the Barrack Hospital, Scutari, on the outskirts of Constantinople, circa 1854 to 1856. Early Life and Education A profession, a trade, a necessary occupation, some- thing to fill and employ all my faculties, I have always felt essential to me, I have always longed for, con- sciouslyornot.... Nightingales and both daughters made an extended —Florence Nightingale, private note, 1850, cited tour of France, Italy, and Switzerland between the in Woodham-Smith (1983, p. From there, Nightingale vis- By all accounts, Nightingale was an intense and ited Germany, making her first acquaintance with serious child, always concerned with the poor and Kaiserswerth, a Protestant religious community the ill, mature far beyond her years. A few months that contained the Institution for the Training of before her seventeenth birthday, Nightingale Deaconesses, with a hospital school, penitentiary, recorded in a personal note dated February 7, 1837, and orphanage. What that Fleidner, and his young wife had established this service was to be was unknown at that point in community in 1836, in part to provide training for time. This was to be the first of four such experi- women deaconesses (Protestant “nuns”) who ences that Nightingale documented. Nightingale was to return there in The fundamental nature of her religious convic- 1851 against much family opposition to stay from tions made her service to God, through service to July through October, participating in a period of “nurses training” (Cook, Vol. What the make it without”(Nightingale, private note, cited in Kaiserswerth training lacked in expertise it made Woodham-Smith, 1983). It would take 16 long and torturous years, from Florence wrote, “The world here fills my life with 1837 to 1853, for Nightingale to actualize her call- interest and strengthens me in body and mind” ing to the role of nurse. Nightingale took two trips to Paris she turned down proposals of marriage, potentially, in 1853, hospital training again was the goal, this in her mother’s view, “brilliant matches,” such as time with the sisters of St. In August 1853, she accepted her need to serve God and to demonstrate her caring first “official” nursing post as superintendent of an through meaningful activity proved stronger. She “Establishment for Gentlewomen in Distressed did not think that she could be married and also do Circumstances during Illness,” located at 1 Harley God’s will.